Provider Demographics
NPI:1861822439
Name:KELLER, JARED BRENT (PA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:BRENT
Last Name:KELLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-737-6718
Mailing Address - Fax:
Practice Address - Street 1:402 6TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1619
Practice Address - Country:US
Practice Address - Phone:208-650-7941
Practice Address - Fax:208-436-0735
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1256363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013041111OtherMISSOURI LICENSE 2013041111
ID1374813Medicare Oscar/Certification